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Abstract
Seizures are common in patients with brain tumors, and epilepsy can significantly impact patient quality of life. Therefore, a thorough understanding of rates and predictors of seizures, and the likelihood of seizure freedom after resection, is critical in the treatment of brain tumors. Among all tumor types, seizures are most common with glioneuronal tumors (70-80%), particularly in patients with frontotemporal or insular lesions. Seizures are also common in individuals with glioma, with the highest rates of epilepsy (60-75%) observed in patients with low-grade gliomas located in superficial cortical or insular regions. Approximately 20-50% of patients with meningioma and 20-35% of those with brain metastases also suffer from seizures. After tumor resection, approximately 60-90% are rendered seizure-free, with most favorable seizure outcomes seen in individuals with glioneuronal tumors. Gross total resection, earlier surgical therapy, and a lack of generalized seizures are common predictors of a favorable seizure outcome. With regard to anticonvulsant medication selection, evidence-based guidelines for the treatment of focal epilepsy should be followed, and individual patient factors should also be considered, including patient age, sex, organ dysfunction, comorbidity, or cotherapy. As concomitant chemotherapy commonly forms an essential part of glioma treatment, enzyme-inducing anticonvulsants should be avoided when possible. Seizure freedom is the ultimate goal in the treatment of brain tumor patients with epilepsy, given the adverse effects of seizures on quality of life.
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Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edward F Chang
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Charles J Vecht
- Service Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Increased risk of epilepsy among patients diagnosed with chronic osteomyelitis. Epilepsy Res 2014; 108:1427-34. [DOI: 10.1016/j.eplepsyres.2014.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/30/2014] [Accepted: 06/17/2014] [Indexed: 11/22/2022]
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Englot DJ, Chang EF. Rates and predictors of seizure freedom in resective epilepsy surgery: an update. Neurosurg Rev 2014; 37:389-404; discussion 404-5. [PMID: 24497269 DOI: 10.1007/s10143-014-0527-9] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 10/26/2013] [Accepted: 10/27/2013] [Indexed: 12/26/2022]
Abstract
Epilepsy is a debilitating neurological disorder affecting approximately 1 % of the world's population. Drug-resistant focal epilepsies are potentially surgically remediable. Although epilepsy surgery is dramatically underutilized among medically refractory patients, there is an expanding collection of evidence supporting its efficacy which may soon compel a paradigm shift. Of note is that a recent randomized controlled trial demonstrated that early resection leads to considerably better seizure outcomes than continued medical therapy in patients with pharmacoresistant temporal lobe epilepsy. In the present review, we provide a timely update of seizure freedom rates and predictors in resective epilepsy surgery, organized by the distinct pathological entities most commonly observed. Class I evidence, meta-analyses, and individual observational case series are considered, including the experiences of both our institution and others. Overall, resective epilepsy surgery leads to seizure freedom in approximately two thirds of patients with intractable temporal lobe epilepsy and about one half of individuals with focal neocortical epilepsy, although only the former observation is supported by class I evidence. Two common modifiable predictors of postoperative seizure freedom are early operative intervention and, in the case of a discrete lesion, gross total resection. Evidence-based practice guidelines recommend that epilepsy patients who continue to have seizures after trialing two or more medication regimens should be referred to a comprehensive epilepsy center for multidisciplinary evaluation, including surgical consideration.
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Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco, CA, USA,
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Ikeda D, Chiocca EA. Editorial: Tumor and antiepileptic drugs. J Neurosurg 2013; 118:1181-2; discussion 1182. [DOI: 10.3171/2012.8.jns121332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Saria MG, Corle C, Hu J, Rudnick JD, Phuphanich S, Mrugala MM, Crew LK, Bota DA, Dan Fu B, Kim RY, Brown T, Feely H, Brechlin J, Brown BD, Drappatz J, Wen PY, Chen CC, Carter B, Lee JW, Kesari S. Retrospective analysis of the tolerability and activity of lacosamide in patients with brain tumors. J Neurosurg 2013; 118:1183-7. [DOI: 10.3171/2013.1.jns12397] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to determine the tolerability and activity of lacosamide in patients with brain tumors.
Methods
The authors reviewed the medical records at 5 US academic medical centers with tertiary brain tumor programs, seeking all patients in whom a primary brain tumor had been diagnosed and who were taking lacosamide.
Results
The authors identified 70 patients with primary brain tumors and reviewed seizure frequency and toxicities. The majority of the patients had gliomas (96%). Fifty-five (78%) had partial seizures only, and 12 (17%) had generalized seizures. Most of the patients (74%) were started on lacosamide because of recurrent seizures. Forty-six patients (66%) reported a decrease in seizure frequency, and 21 patients (30%) reported stable seizures. Most of the patients (54 [77%]) placed on lacosamide did not report any toxicities.
Conclusions
This retrospective analysis demonstrated that lacosamide was both well tolerated and active as an add-on antiepileptic drug (AED) in patients with brain tumors. Lacosamide's novel mechanism of action will allow for concurrent use with other AEDs, as documented by its activity across many different types of AEDs used in this patient population. Larger prospective studies are warranted.
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Affiliation(s)
| | | | - Jethro Hu
- 2Cochran Brain Tumor Center, Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles
| | - Jeremy D. Rudnick
- 2Cochran Brain Tumor Center, Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles
| | - Surasak Phuphanich
- 2Cochran Brain Tumor Center, Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles
| | - Maciej M. Mrugala
- 3Departments of Neurology and
- 5Neuro-Oncology Center, University of Washington School of Medicine, Seattle, Washington
| | - Laura K. Crew
- 4Neurological Surgery, and
- 5Neuro-Oncology Center, University of Washington School of Medicine, Seattle, Washington
| | - Daniela A. Bota
- 6Departments of Neurology and
- 7Neurological Surgery, and
- 8Chao Family Comprehensive Cancer Center, School of Medicine, University of California, Irvine, California
| | | | | | | | - Homira Feely
- 1Departments of Neurosciences and
- 9Neurosurgery, Moores Cancer Center, University of California, San Diego, La Jolla
| | | | | | - Jan Drappatz
- 10Department of Neurology, Brigham and Women's Hospital; and
- 11Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Patrick Y. Wen
- 10Department of Neurology, Brigham and Women's Hospital; and
- 11Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Clark C. Chen
- 9Neurosurgery, Moores Cancer Center, University of California, San Diego, La Jolla
| | - Bob Carter
- 9Neurosurgery, Moores Cancer Center, University of California, San Diego, La Jolla
| | - Jong Woo Lee
- 10Department of Neurology, Brigham and Women's Hospital; and
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Jayasekera BAP, Bacon AD, Whitfield PC. Management of glioblastoma multiforme in pregnancy. J Neurosurg 2012; 116:1187-94. [DOI: 10.3171/2012.2.jns112077] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Glioblastoma multiforme presenting during pregnancy presents unique challenges to the clinician. In planning treatment, potential benefits to the mother must be balanced against the risks to the fetus. In addition, evidence relating to timing of surgery and the use of radiotherapy and chemotherapy in pregnancy is limited. Management of peritumoral edema and seizures in pregnancy is also complicated by the potential for drug-related teratogenic effects and adverse neonatal outcomes on the fetus. The general anesthetic used for surgery must factor obstetric and neurosurgical considerations.
In this review article, the authors seek to examine the role, safety, and timing of therapies for glioblastoma in the context of pregnancy. This covers the use of radiotherapy and chemotherapy, timing of surgery, postoperative care, anesthetic considerations, and use of anticonvulsant medications and steroids. The authors hope that this will provide a framework for clinicians treating pregnant patients with glioblastomas.
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Affiliation(s)
| | - Andrew D. Bacon
- 2Department of Neurosurgery, Frenchay Hospital, Bristol; and
| | - Peter C. Whitfield
- 3Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, United Kingdom
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Englot DJ, Berger MS, Barbaro NM, Chang EF. Predictors of seizure freedom after resection of supratentorial low-grade gliomas. A review. J Neurosurg 2011; 115:240-4. [PMID: 21529134 DOI: 10.3171/2011.3.jns1153] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT Seizures are the most frequent presenting symptom in patients with low-grade gliomas (LGGs), and significantly influence quality of life if they are uncontrolled. Achieving freedom from seizures is of utmost importance in surgical planning, but the factors associated with seizure control remain incompletely understood. METHODS The authors performed a systematic literature review of seizure outcomes after resection of LGGs causing seizures, examining 773 patients across 20 published series. Rates of seizure freedom were stratified across 7 variables: patient age, tumor location, preoperative seizure control with medication, seizure semiology, epilepsy duration, extent of resection, and the use of intraoperative electrocorticography (ECoG). RESULTS Gross-total resection was most predictive of complete seizure freedom, when compared with subtotal resection (OR 3.41, 95% CI 2.36-4.93). Other predictors of seizure freedom included preoperative seizure control on antiepileptic medication (OR 2.12, 95% CI 1.33-3.38) and duration of seizures of ≤ 1 year (OR 1.85, 95% CI 1.22-2.79). Patients with simple partial seizure semiology achieved seizure freedom less often than those with complex partial, generalized, or mixed seizure types (OR 0.46, 95% CI 0.26-0.80). No significant differences in seizure outcome were observed between adults versus children, patients with temporal lobe versus extratemporal tumors, or with the use of intraoperative ECoG. CONCLUSIONS Seizure control is one of the most important considerations in planning surgery for low-grade brain tumors. Gross-total resection is a critical factor in achieving seizure freedom.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Kargiotis O, Markoula S, Kyritsis AP. Epilepsy in the cancer patient. Cancer Chemother Pharmacol 2011; 67:489-501. [PMID: 21305288 DOI: 10.1007/s00280-011-1569-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/21/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Epileptic seizures in patients with malignancies usually occur as a consequence of brain metastases from systemic cancer or the presence of a primary brain tumor. Other less-frequent causes include metabolic disorders such as electrolyte abnormalities, hypoglycemia, hypoxia and liver failure, paraneoplastic encephalitis, leptomeningeal carcinomatosis, side effects of certain chemotherapeutic agents, central nervous system infections, and pre-existing epilepsy. METHODS We reviewed all published literature in the English language regarding the use of antiepileptic drugs in patients with cancer. RESULTS In patients with brain metastases or primary brain tumors that had never experienced seizures, prophylactic anticonvulsant treatment is justified only for a period up to 6 months postoperatively after surgical excision of a cerebral tumor, since approximately half of the patients will never develop seizures and the anti-epileptic drugs may cause toxicity and interactions with antineoplastic therapies. For brief prophylaxis, newer antiepileptic drugs such as levetiracetam and oxcarbazepine are superior to older agents like phenytoin. In patients with a malignancy and seizures, certain antiepileptic drugs that express tumor inhibitory properties should be used such as valproic acid and levetiracetam, followed by oxcarbazepine and topiramate that exhibit good tolerance, efficient seizure control and absence of significant interactions with the chemotherapy. CONCLUSIONS Future clinical trials in patients with cancer and epilepsy should focus on combinations of chemotherapeutic interventions with antiepileptic drugs that demonstrate antineoplastic activities.
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Affiliation(s)
- Odysseas Kargiotis
- Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece.
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